Clinical Medicine Insights. Case Reports最新文献

Background: Olfactory nerve schwannomas are sporadic, benign neurogenic tumors arising from Schwann cells within the olfactory pathway. Their clinical presentation is typically nonspecific, and diagnosis often requires careful radiologic and histopathologic evaluation.

Case presentation: We describe a 19-year-old male patient with an olfactory schwannoma that was incidentally discovered during evaluation for head trauma. The patient was asymptomatic, with preserved olfactory function.

Management and results: The patient underwent complete surgical excision via bifrontal craniotomy. Immunohistochemical staining demonstrated positivity for S100, CD34, and Bcl-2, and negativity for GFAP and EMA, confirming the diagnosis of schwannoma. The postoperative course was uneventful, with full preservation of olfactory nerve function, and the patient was discharged in stable condition on postoperative day 7.

Conclusion: This case highlights the clinical significance of recognizing olfactory schwannomas, which may be discovered incidentally. Comprehensive imaging and histopathological evaluation are crucial for accurate diagnosis. Early detection and total resection contribute to favorable neurological outcomes in asymptomatic patients.

Introduction: The increasing use of advanced imaging modalities has led to a growing number of Incidental thyroid nodules (ITNs). Although most ITNs are benign, dedicated evaluation with a thyroid ultrasound (US) is strongly recommended to assess malignancy risk with a dedicated.

Case presentation: We report a case of a 66-year-old male with large fluorodeoxyglucose (FDG)-avid right thyroid mass identified incidentally on a positron emission tomography (PET) scan. Initial fine needle aspiration (FNA) suggested benign pathology. However, subsequent thyroid US demonstrated highly suspicious features concerning for lymphoma or sarcoma, prompting a core biopsy with flow cytometry and immunohistochemistry, which confirmed a diagnosis of small lymphocytic B-cell infiltrating the thyroid gland.

Conclusion: This case underscores the diagnostic limitation of FNA in detecting thyroid lymphoma and highlights the critical role of thyroid US in identifying concerning features. When US findings are highly suspicious for lymphoma, additional diagnostic approaches - including core biopsy with flow cytometry and immunohistochemistry - are essential to ensure accurate diagnosis and appropriate management.

Introduction: Achilles tendon xanthomas are uncommon lipid-rich lesions associated with familial hypercholesterolemia, typically affecting adult patients. Presentation during childhood or adolescence is uncommon, particularly among female patients, and often indicates severe underlying dyslipidemia. Early recognition is important to prevent long-term complications.

Case presentation: A 17-year-old Indian girl presented with bilateral posterior ankle swelling and discomfort. Clinical examination revealed firm, non-tender, fusiform swellings adherent to both Achilles tendons. Laboratory evaluation revealed elevated low-density lipoprotein cholesterol and apolipoprotein B levels, consistent with heterozygous familial hypercholesterolemia. Magnetic resonance imaging (MRI) of both ankles demonstrated diffuse tendon thickening with a hypointense signal on T2-weighted sequences and speckled heterogeneity on proton density fat-suppressed images, confirming xanthomatosis. Surgical excision was performed on the right side, and histopathological examination confirmed the presence of foam cells and cholesterol clefts. The left-sided swelling was managed conservatively, with serial follow-up demonstrating stable morphology and no progression.

Discussion: Radiological assessment using MRI allowed a clear distinction between xanthomas and other tendinopathies. Given the patient's functional limitations, surgery provided mechanical relief, whereas lipid-lowering therapy addressed the underlying systemic risk.

Conclusion: Recognition of tendon xanthomas in adolescents supports timely identification of hereditary dyslipidemia and initiation of coordinated orthopedic and metabolic care, with potential long-term cardiovascular benefit.

Introduction: Pseudomonas aeruginosa is a frequent cause of healthcare-associated infections and is increasingly encountered in extensively drug-resistant (XDR) or pan-drug-resistant (PDR) forms. Such strains leave clinicians with virtually no therapeutic options and carry high mortality.

Case presentation: We describe a 66-year-old man with chronic hypoxic respiratory failure, chronic kidney disease, and recurrent infections who was admitted with septic shock. Initial broad-spectrum antibiotics were ineffective, and cultures yielded PDR Pseudomonas aeruginosa, resistant to cefiderocol and with borderline colistin susceptibility (MIC 2 µg/mL). Antimicrobial susceptibility testing was performed by broth microdilution on a Thermo Fisher Sensititre™ GNX3F panel, with colistin MIC confirmed by reference broth microdilution; results were interpreted per EUCAST v13.0 (2025) and CLSI M100 (2025). Despite high-dose intravenous colistin, cefiderocol, and adjunctive amikacin, the infection persisted, leading to progressive multi-organ dysfunction. Colistin dosing was adjusted for renal insufficiency and subsequently for continuous renal replacement therapy (CRRT). Meropenem (MIC 8 µg/mL; resistant) was trialed in combination with colistin for potential pharmacodynamic synergy. After 12 days of intensive care, and following discussion with family, care was redirected to comfort measures, and the patient died. The cause of death was refractory septic shock due to PDR Pseudomonas aeruginosa with multi-organ failure.

Discussion: This case illustrates the therapeutic futility posed by pan-drug-resistant (PDR) Pseudomonas aeruginosa. Colistin's limited efficacy at borderline MICs, compounded by renal impairment, constrained dosing. Even newer agents such as cefiderocol proved ineffective. Experimental therapies, including bacteriophages, novel β-lactamase inhibitors, and antimicrobial peptides, remain unavailable in most clinical settings.

Conclusion: PDR Pseudomonas aeruginosa represents an urgent global threat. Until novel therapies become accessible, stringent stewardship, infection control, and preventive strategies remain the most effective defenses.

Internal abdominal hernias are rare causes of small bowel obstruction but carry a high risk of strangulation and bowel ischemia if not promptly recognized. We report the case of a 92-year-old man with a virgin abdomen who presented with acute abdominal pain and was found on computed tomography to have a closed-loop obstruction with a mesenteric "whirl sign." Emergency laparotomy revealed the presence of a necrotic colonic loop strangulated by an internal adhesion with no history of prior abdominal surgery or trauma. Segmental colectomy with creation of a protective double-barrel ileostomy was performed, followed by uneventful recovery and subsequent reversal of the ileostomy. This case highlights the importance of considering internal hernia in elderly patients with bowel obstruction and no previous surgery, the value of CT and the "whirl sign" in raising early suspicion of a closed-loop process, and the need for timely surgical intervention to prevent any irreversible ischemic injury.

Idiopathic scrotal calcinosis is a rare, benign condition of uncertain etiology that typically begins in adolescence or early adulthood. Although often asymptomatic, patients usually seek medical attention for cosmetic concerns and may also report pruritus, soreness, or discharge of a white, chalky material from the nodules, occasionally accompanied by secondary infection. This condition occurs in the absence of calcium or phosphate metabolism abnormalities. We present a case series of patients with idiopathic scrotal calcinosis who underwent surgical excision of the involved scrotal skin or enucleation of individual cysts. In Case 1, resection of scrotal skin containing multiple nodules was followed by primary closure. Case 2, a 24-year-old male, underwent wide excision of scrotal skin with primary repair. In a 19-year old male (Case 3, a sleeve of scrotal skin containing a dominant nodule(s) was excised, while Case 4, an 18-year-old male, underwent enucleation of individual nodules. All patients showed good surgical & cosmetic outcomes during follow-up, with no postoperative complications and a high level of satisfaction with the results. Here we discuss the clinical features, pathogenesis and surgical management of this rare condition.

We report a rare case of childhood-onset Minimal Change Disease (MCD) in a 31-year-old male, originally diagnosed at age 2.5 with nephrotic syndrome. Repeated biopsies throughout his childhood and adolescence revealed normal glomeruli on light microscopy and diffuse effacement of podocyte foot processes on electron microscopy, confirming pure MCD. Despite multiple relapses, prolonged corticosteroid therapy, and adjunctive immunosuppressants including cyclosporine, tacrolimus, and 2 courses of Rituximab, the patient developed progressive renal decline culminating in end-stage renal disease (ESRD) and initiation of maintenance hemodialysis in August 2025. His course also included an ischemic stroke at age 20. This case illustrates an atypical, aggressive phenotype of MCD, without transformation to focal segmental glomerulosclerosis, that challenges the conventional prognosis of MCD and underscores the need for long-term monitoring and reporting of such exceptional cases.

Introduction: Self-managed second-trimester medical abortion has become increasingly common, especially where access to clinical services is limited. Although misoprostol is generally safe when used in evidence-based regimens, unsupervised or excessive dosing can lead to severe complications. Uterine rupture is a rare, life-threatening event that typically occurs in laboring women with prior uterine surgery. We report a case of spontaneous rupture of an apparently unscarred uterus at 22 weeks gestation following unsupervised misoprostol use.

Case presentation: A 30-year-old G3P2 woman at ~22 weeks presented with abdominal pain and scant bleeding after self-administering misoprostol (total 3000 µg over 48 hours) for abortion. She had 2 prior uncomplicated vaginal deliveries and no uterine surgery. Clinical evaluation and bedside ultrasound revealed an intact intrauterine fetus with free fluid consistent with hemoperitoneum. Hemodynamic instability prompted urgent laparotomy. Intraoperatively, a 5-cm full-thickness transverse rupture of the anterior lower uterine segment with necrotic edges was found, with the demized fetus in the peritoneal cavity. After debridement, the uterine defect was repaired in 3 layers; hysterectomy was averted. Two units of blood were transfused; broad-spectrum antibiotics and thromboprophylaxis were given.

Management and outcome: Postoperative recovery was uneventful. The patient stabilized, completed antibiotics, and was discharged on day 5 with a progestin implant for contraception. At 6-week follow-up, she was asymptomatic and imaging showed a healed uterine repair.

Conclusion: This case explicitly shows that unsupervised high-dose misoprostol regimens can precipitate catastrophic uterine rupture even in an unscarred, mid-trimester uterus. Early recognition and prompt surgical management allowed uterine preservation. Clinicians should maintain a high index of suspicion for rupture in women presenting with pain and intra-abdominal bleeding after self-managed abortion. This case tries to emphasize the need for safe abortion access, patient education on proper dosing, and post-abortion follow-up with contraception counseling.

Background: A gastric fistula (GF) is defined as an abnormal communication between the gastric mucosa and an adjacent anatomical structure.

Case presentation: We report a 30-year-old male patient who developed a subcardial gastric fistula after sleeve gastrectomy. It was successfully treated using the Over-the-Scope Clip (OTSC) system as a non-surgical approach.

Conclusion: This case demonstrates the effectiveness and feasibility of the over-the-scope clip device for closure of post-bariatric gastric fistulas and highlights its applicability when surgical intervention carries significant risks.

Introduction: Polydrug overdose, defined as the simultaneous ingestion of multiple toxic substances, is increasingly encountered in emergency departments. Overlapping toxidromes often obscure the causative agents, complicating diagnosis and management. Acetaminophen (APAP) overdose can cause hepatotoxicity through N-acetyl-p-benzoquinone imine (NAPQI) formation, metoclopramide may precipitate acute extrapyramidal symptoms, and metronidazole can induce neurotoxicity, typically a cerebellar syndrome.

Case summary: Young adult male medical student intentionally ingested 12 g of APAP, 170 mg of metoclopramide, and 8 g of metronidazole. He presented 24 hours later with repeated vomiting, tremor, rigidity, dysarthria, gait ataxia, and transient confusion. Vital signs were stable; laboratory tests showed transaminase elevation and coagulopathy. Peak AST/ALT were 100/76 U/L and INR peaked at 1.74. Management included oral N-acetylcysteine for APAP toxicity, intravenous diphenhydramine and diazepam for extrapyramidal symptoms, supportive ICU care, and psychiatric intervention. Coagulopathy was corrected with fresh frozen plasma. Neurological and hepatic abnormalities resolved within 72 hours, and the patient remained asymptomatic at 2-week follow-up. The patient recovered fully after N-acetylcysteine and supportive care, illustrating the diagnostic challenges of overlapping toxidromes.

Conclusion: This case highlights the diagnostic and therapeutic challenges of polydrug overdose with overlapping toxidromes. Rapid identification and agent-specific management, including NAC for APAP, symptomatic therapy for metoclopramide and metronidazole toxicity, and supportive care, resulted in full recovery without long-term sequelae. Emergency clinicians should maintain high suspicion for multiple co-ingestants and use targeted interventions to optimize outcomes.